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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPAf2TMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RE�O q5
<br />DATE OF ISSUANCE . '+�-� �
<br />;. ��/��Q�� L�
<br />OZ/OS/ZO'I2 Q - STAMLEI' S.~�iOQ�ER, ' ` ,
<br />� O�� O S O�� DEP R�MENT D H�ALTH AND ._ '
<br />LINCOLN, NEBRASKA HUMA`IJ�S�R�/,I�CEB,"
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC�S `�^'.; �°'�; � 2 0028'I
<br />GCK111'IGAICVtUtAltl °,�„ �� ,,�;;• �, �
<br />7. DECEDENTB•NAMB (Flrat, Middle, Last, Suflbc) 2. SD( '.�� 3. DATE OP DEATH (Mo., Day, Yr.)
<br />Vermoyne Dale Wlese Male ' � Jaiivary 27, 2012
<br />4. CITY AND 3TATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Birthday b. UNDER 7 YEAR Sc. UNDER 7 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(YB•) MOS. DAY9 HOURS NtlNS.
<br />`Hall Coun , Nebraska 75 Dacember 13, 1936
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />505-54-3044 HOSPRAI � Inpatlerrt OTHER ❑ Nursing Homell.TC � Hosplee Faelllty
<br />8b. FACILITY-NAAAE (If �rot trmtitutlon, ghe street ami number) ❑ ER/Ouq�aUe� ❑ Decederrt s Home
<br />�
<br />� Saint Francts Medical Center ❑ DOA ❑ o�ner (speary>
<br />v
<br />� 8c. CITY OR TOWN OF DEATH pnciude Zlp Coda) 8d. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCESTATE 8b. COUNTY 9e. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />� Bd. STREET AND NUMBER . APT. NO. 9L ZIP CODE 9g. INSIDE CITY LIIVOTS
<br />� 4612 North 70th Road 68803 ❑ r�s � No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH � AAarHed ❑ Never Marri�! 70b. NAME OF SPOUSE (Fhst, Middle, Last, Suffbc) If wife, give rtmlden name
<br />� ❑ n�maa but eeparated ❑ Wldowed ❑ on�o�a ❑ u��ow� gemice New
<br />� 11. FATHER'S•NAME (Firat, Middle, Last, SuffUc) 12. MOTHER'S•NAME (First, Mlddle, Malde� Sumame)
<br />m Arthur Wiese Linda Boltz
<br />E 13. EVER IN U.S. ARMED FORCES? Glve dates of servic6 If Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />� (Yea,No,orunk.)Yes 07/15/1960 BemiCe Wfese W�fe
<br />,$ 18. METHOD OF DISPOSITION 78a. EMBALMERyrIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F � BuMal ❑ DoreUon
<br />Ch�is McCoy 1191 January 30, 2012
<br />❑ CremaUon ❑ EMombmarrt 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />���� ��� � Grand Island City Cemetery Grand Island Nebraska
<br />1Ta. FUNERAL HOME NAME AND MAILING ADDRE38 (Street, City or Town, State) 77b.21p Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF EAT See Instructlons and exam les
<br />1& PART 4 EMerthe ahein M evaMS.d�seasea, InJurles. or wmpticatlons-fhat dlre�Yiy ceused the death. DO NOT e�ner tenNnai eveMe euch es cardiac ertest, 0 APPRO70MATE INTERVAL
<br />respiratory erteat, m veMriwlar flbNllaUOn without ahowing Me etiotog�r. DO NOT ABBREVIATE Ertter onty one cat�se an a Ma Add atlNtloimi Wres B�ary.
<br />IMMEDWTE CAUSE: ; onset W death
<br />aameou►re cnuse cFUm� a) Respiratory Failure E< 1 Week
<br />dl� orcontlitlon resuitlng
<br />In death) DUE TO, OR /6S A CONSEQUENCE OF: : onset to death
<br />s��hum��amo�e,u b)Hypoxic Brain Injury E< 1 Week
<br />anr. �aam� to �re muse �tama
<br />on Ii�re a DUE TO, OR AS A CONSEQUENCE OF: i O�et to death
<br />F,�rterthe UNDERLYINO CAUSE �I Food Aspiration :< 1 Week
<br />(d�eease or InJury that Initlated
<br />� 0181 �"�n"e �"'�'� DUE TO, OR A3 A CONSEQUENCE OF: � o�et to death
<br />� d)
<br />18. PART 11. OTHER SIONIFlCANT CONDITIONS-CortdlUotre coMrtbuting to the death but rrot reaulting In the u�erlytng cauae givan In PART L 19. WAS MEDICAL EXAMINER
<br />Cardiomyopathy OR CORONER CONTACTED?
<br />� ❑ vES � No
<br />LL q. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />� Q Nat pregnarrt wfthln past year � NaWral � Homldde � DHver/Operator �� � NO
<br />W PregnaM et tlme oi death � Paseenger
<br />V � AcddeM � Pandln8 ���eatl8�on
<br />� � NM pregnant, but pregna�rt wkhin 42 daye ot deatl� Suldde Could not be eetermined ❑ Pedestrtan 21d. WERE AUTOPSY FlNDINGS AVAILABL
<br />� Not pregneM, 6ut pregna�rt 43 tlaye m t year before death � � � Other (Bpeclry► TO COMPLETE CAUSE OF DEATH?
<br />� ❑ res ❑ No
<br />� � Unlmown It pregnant wltMn the paet year
<br />� . DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY•At home, tarm, streat, iactory, otflce bu1ldU�g, corretruction site, etc. (Specify)
<br />8 Janua 20, 2012 01:00 PM Home °
<br />� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F Food aspiration
<br />❑ ves � No
<br />22t. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITY/tOWN STATE ZIP CODE
<br />4612 North 70th Road, Grand Island Nebraska 68803
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DA7E SIONED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />� January 27, 2012 � � �
<br />� r 23b. DATE SIONED (Mo., Day, Yr.) 23c. TIME OF DEATH ��' � y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� Z Janua 30, 2012 06:32 AM � 6 a�
<br />� � . To the best af my Imowiadge. death oaurtetl at Me dme, da[e erM ptace $ !5 � 24e. On the b�ls otexeminadon and/or Mvestlgatlon, ln my oplNOn death oewrtad at
<br />��� and due to tlre rause(e) s�ted (S�Brtature m�tl Titte) � S Ure Ume� dete end ptece antl due to Ure cauae(s) statetl. (sig�mture and Tltie)
<br />~ Jennifer L. Brown, MD ~ � �
<br />a
<br />2. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HA3 ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />❑ YES ❑ NO ❑ PROBABLY � UNKNOWN ❑ YES � NO NotApplieable N26a is NO ❑ YES ❑ NO
<br />2 � E, D R IFIER (P S , H T, COR S P 1 IAN R COU A E1n (fype or rlr�t
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE � 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />January 30, 2012
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